Tracheostomy

Dr. John McCormick-Deaton, DOGeneral Surgery

PGY-2

Purpose/Description

• Elective procedure• Provides a more secure airway• Improves Pt comfort• Improves Oral Hygiene• Increases Pt mobility• Enhances secretion removal

Indications

• Prolonged intubation• Need for secure airway in Maxillofacial injury• Upper Airway obstruction• Need for secure airway in Neurological

disorders

Complications

• Bleeding• Wound Infection• Tube dislodgement/malposition• Pneumothorax, pneumomediastinum, SubQ emphysema• Esophageal perforation• Tracheal malacia• Tracheal Stenosis• Fistulas: tracheoesophageal, tracheoinnominate artery (TIAF)

– Occurs Rarely (~0.3%)– 50-80% mortality rate

• RLN Injury

Downsize

• Large caliber, non-fenestrated, cuffed tube to Small caliber, fenestrated uncuffed tube.– Allows for normal speech• Intermittent finger occlusion• Passy-Muir valve

– Facilitates stoma closure

Removal

• Original indication for tracheostomy resolved • Tolerate capping >24hrs• If upper airway mass or tissue reconstruction

was original indication; pre-decanulation flexible laryngoscopic exam recommended.

Landmarks

Anatomy

Anatomy

• ~11.8 cm Long• 18-22 cartilaginous rings• Blood supply– Inferior thyroid– Internal thoracic– Supreme intercostal– Bronchial arteries

• Begins ~1.5cm below the Vocal Cords• ~50% of the trachea is cervical w/ hyperextension

Procedure

• Vertical or Horizontal incision made over the 2nd or 3rd tracheal rings.– Carried through the platysmas

• Blunt dissection of Strap Muscles• Gently retract Thyroid/Isthmus – retracted cranially – May need to divide

Procedure

• Stay sutures placed laterally to ostomy incision site– Can be used as traction– Landmark if dislodgement occurs

• Midline trachea incised at 2nd and 3rd ring– Must preserve 1st tracheal ring– Do not puncture ETT cuff

• ETT deflated and withdrawn proximal to ostomy site by Anesthesia

Procedure

• Tracheal spreader to gently enlarge ostomy and accommodate trach

• Remove inner cannula and attach to vent to ensure proper placement

• Remove ETT• Close w/ simple skin sutures• Flange is secured w/ sutures and tied around

neck

Procedure

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